New pharmacist reproof
October 21, 2015
A CANBERRA pharmacist who
made a dispensing error just a
month after being registered in
2012 has been reprimanded by
the ACT Civil and Administrative
Tribunal for unprofessional conduct
following an incident in the Phillip
Chemist Warehouse store.
Mandy Wang was found
responsible for the accidental
dispensing of Lanoxin (digoxin)
250mcg one bd instead of Lasix
(furosemide ) 250mcg one bd as
the prescription defined.
A high workload in the busy store
was blamed as part of the problem,
when the script which was laid out
in the waiting area by one of the
four dispensary technicians on duty
at the time along with Wang and
another registered pharmacist.
The patient concerned, who had
chronic kidney failure from the
age of three weeks and had had
a kidney transplant in 2002, was
consequently administered four
times the normal dose of digoxin
for a patient with renal impairment,
resulting in severe toxicity with
vomiting and diarrhoea.
The patient had ongoing problems
from the medication including two
weeks of sick leave from work.
Wang, who has repeatedly
expressed remorse, said at the
hearing that the mistake could have
been prevented had “more rigorous
dispensing procedures” been
implemented at the pharmacy.
The Pharmacy Board has ordered
that Wang complete the Ethics and
Dispensing in Pharmacy Practice
course from the Pharmaceutical
Society of Australia within nine
months of the order.
Although the incident happened
over three years ago the hearing
was only concluded this week.
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